V06-07: Robotic-assisted Laparoscopic Nerve Sparing Cystectomy
It has been recently proven that robotic cystectomy was non-inferior to open cystectomy for 2-year progression-free survival. It seems clear that robotic cystectomy offers lower rates of blood loss and transfusions compared to open cystectomy. However, it has yet to be determined if Intracorporeal Urinary Diversion, compared with Extracorporeal Urinary Diversion, has a lower risk of complications. We sustain that robotic cystectomy can offer better outcomes in nerve sparing. Therefore, in this video we present the technique we have used and the results we have obtained.
We initiate the intervention performing the liberation of the seminal vesicles with Montsouris technique. We then make and incision in the peritoneum and dissect the vas deferens and seminal vesicles. After pulling the vas deferens, the Denonvilliers fascia is exposed. It can be safely open, so that we are able to create a posterior, intrafascial dissection plane to reach the apex of the prostate. When the ureter and the lateral pedicles of the urinary bladder are sectioned, and the endopelvic fascia is open, we perform a dissection of the intrafascial lateral plane of the prostate. Thus, we are able to safely clamp the vascular pedicles of the prostate and put together the two intrafascial planes, which are carefully widened to reach the uretra. We liberate the urethra so that we are able to separate it from the bundles. The urethra is clamped to avoid the dissemination of the tumoral cells, and then sectioned.
We operated 51 patients with a mean age of 58.3; of those 46 were males. An Extracorporeal Urinary Diversion was performed in 14 of them, while 37 had an Intracorporeal Urinary Diversion. The ASA score was 2 in 24 of the patients, and 3 in 27 of them. Neoadjuvant chemotherapy was administered in 27 patients. A nerve sparing cystectomy was performed in 31 of them. The mean operating time was 406 minutes. There was no need to reconvert any operation. The estimated blood loss was 775 mL and 35% of the patients required a transfusion. The average length of hospital stay was 11.8 days. The majority of the tumors had urothelial origin, and the pathological stage varied widely. We have removed an average of 16.2 adenopathies. 3 of the patients were classified as N1 stage, and other 3 as N2 stage. All resection margins were tumor-free. Mean progression-free survival at 2 years from the operation was 71%. 91% of the 31 men undergoing nerve sparing were potent with or without phospho-diesterase type 5 inhibitors
In our series, the preservation of neurovascular bundles through the technique described above offers great outcomes.